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INSIGHTS INTO THE TREATMENT OF ADHD
EPSTEIN QUARTERLY
Updated October, 2003
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INTRODUCTION
Parents are always concerned about using medication when it is recommended for their
ADHD child. Because of their feelings, there are many questions asked about the
effectiveness of medication and other possible approaches to make the use of medication
unnecessary. A recent landmark study addresses both of these concerns. It gives us
information about the most effective treatments for ADHD and offers additional insights
that will be useful to parents and therapists. Because I think the findings are of great
importance, this issue of the Epstein Quarterly will discuss and comment on the study.
THE RESEARCH STUDY
In the Archives of General Psychiatry, Volume 56, No. 12, December 1999 there are two
articles reporting the results of an extensive study of the treatment of ADHD. In this
study, a group of 579 children ages 7 to 9.9 were evaluated over a period of 14 months.
The study was carried out at six different sites, including one in Canada.
CHILDREN CHOSEN
All the children were between 7 and 9 and in grades 1 through 4. They all met the
criteria of DSM-IV for ADHD of the combined type (hyperactive and inattentive). Other
psychiatric conditions existed in many of the children. Among others, these included
oppositional defiant disorder, conduct disorder, and depression.
THE METHOD OF THE STUDY
By randomization methods, a child was assigned to one of four groups. One group was
medication alone, the second intensive behavioral treatment alone, and the third a
combination of behavioral treatment and medication. A fourth was treatment by
"community care."
Medication management involved careful titration of medication, including a period in
the study when medication was compared with placebo. After the appropriate dose of
medication was determined, the child was seen half an hour per month in a medication
evaluation follow-up visit. The medication used in the study was Ritalin.
Behavioral treatment included parental training, child-focused treatment, and
school-based intervention.
Community care was whatever was provided by the community resources. Some of these
children did receive medication, others did not. The decision of how the ADHD child was to
be handled was made in the community and not controlled by the study.
LENGTH OF THE STUDY
This study was carried on over fourteen months. Since most previous studies were four
months in length, this represented a much longer period of study than we had before.
RESULTS
The core ADHD symptoms of distractibility and inattention were treated best by
medication. In fact, these symptoms were not well controlled when the treatment did not
include medication.
As noted above, the study included children with several possible psychiatric
conditions in addition to ADHD. For this group with more than one diagnosis (comorbid
conditions), treatment with stimulant medication alone was not enough. The children with
both ADHD and some other problem did best with the combination of medication and behavior
therapy.
Those in the community care group did show improvement, but it was not as effective as
either the medication alone or combined medication-behavioral groups.
SIGNIFICANCE OF THE STUDY
It is quite clear that the symptoms of hyperactivity and inattention due to ADHD
improve significantly with Ritalin. It is also apparent that a treatment plan without
medication will be much less successful in the treatment of ADHD.
Hopefully, these findings will reduce the controversy over the use of the medication
because we now have such clear evidence of its effectiveness as compared to other
treatments.
The use of medication alone, however, resulted in successful treatment for only between
thirty and fifty percent of the children in the group. This means that at least half of
the children with ADHD need some treatment in addition to medication. Most of these appear
to be children with a second diagnosis who need behavioral treatment in addition to the
medication.
In order to provide appropriate treatment, it is quite clear that we need a careful
evaluation of the patient. It is not satisfactory to allow one or two symptoms to dictate
treatment. The professional must look for problems of both ADHD and other psychiatric
difficulties. Once the picture is complete, we can be confident about the direction
treatment should take.
While medication should be a part of the treatment, in many cases work will have to be
done with the family, child and school to address the ADHD and other issues. The type of
treatment and the length of time needed are, of course, variable and depend on the
circumstances of each case. But it would be helpful if the therapist developed a plan to
involve all aspects of the treatment and proceed from that point.
IMPRESSIONS
This research project was an enormous undertaking and has yielded valuable information.
While it is easy to say, "of course, I knew that" to the findings, this is an
actual scientific study that goes well beyond our intuitions, even if they were correct.
It now allows the therapist to present a program to the family, knowing there is
research evidence to support the planning. I think this will make therapists more
comfortable about recommending medication and will make families feel more comfortable and
less guilty.
It also means that those who only prescribe medication for the treatment of ADHD should
carefully review each case to be sure that other pathology is not being overlooked. It is
a fact that medication can be helpful, but we cannot overlook the finding that best
results are obtained in cases with a comorbid diagnose by a combination of medication and
behavioral therapy.
CONCLUSION
In a study that is not easy to read, a careful study of 579 ADHD children is reported.
The study is of great importance as it defines the most effective treatment approaches for
difficult clinical problems. Therefore, these findings are of interest to therapists,
physicians and families and should be very useful in defining appropriate treatment.
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